Rheumatoid arthritis (RA) is a chronic systemic inflammatory autoimmune
disease. Main characteristics include symmetrical synovitis and joint erosion;
extra-articular manifestations affect the lungs, eyes, heart, and blood vessels.
RA affects approximately 1% of the population, striking women in a 3:1 ratio to
men. The usual age of onset lies between 30 and 60, but the disease can strike
at any age. Symptom severity and disease progression vary widely between
individuals. Onset may be rapid or insidious.
The etiology of RA remains elusive, but a genetic link involving the major
histocompatibility complex class II antigens has been identified. Medical
researchers suspect that environmental factors in conjunction with genetic
predisposition may trigger RA.
- Genetic predisposition
- Environmental factors may include bacterial or viral infection and
- Psychological stress (possible)
- Female gender
- Typically ages 30 to 60, although RA occurs at all
|Signs and Symptoms|
- Malaise, low-grade fever, weight loss, and stiffness in and about
joints following inactivity
- Morning stiffness lasts for more than one hour
- Arthritis of more than three joints; specifically, proximal
interphalangeal, metacarpophalangeal, wrist, elbow, knee, ankle, and
- At least one affected hand joint; specifically, wrist,
metacarpophalangeal, or proximal interphalangeal joint
- Extra-articular symptoms such as rheumatoid nodules, pleural
effusion, pericarditis, lymphadenopathy, splenomegaly with leukopenia,
vasculitis, normochromic, normocytic anemia, and elevated
- Ankylosing spondylitis and seronegative
- Diffuse connective tissue disease, including systemic lupus
erythematosus, scleroderma, dermatomytosis/polymyositis, vasculitis, and mixed
connective tissue disease
- Other forms of arthritis, including infectious arthritis, reactive
arthritis, and osteoarthritis
- Glucocorticoid withdrawal syndrome
- Gout, pseudogout
- Calcium pyrophosphate dihydrate deposition disease
- Chronic fatigue syndrome
- HIV infection
- Intermittent hydrarthrosis
- Lyme disease
- Malignancy, occult malignancy
- Parkinson's disease (with regard to swan neck deformities of the
- Polymyalgia rheumatica and giant cell
The patient experiences joint stiffness, tenderness, and pain; the affected
joints are swollen and may be warm to the touch. Approximately 20% of patients
present with subcutaneous nodules located over bony prominences or within bursas
or tendon sheaths. Some patients exhibit splenomegaly and lymph node
enlargement; low-grade fever, anorexia, weight loss, fatigue, and weakness are
more common. In advanced cases, symptoms include skin and muscle atrophy;
dryness of the eyes, mouth, and other mucous membranes; and physical
Blood tests reveal several abnormalities:
- Rheumatoid factor (IgM antibody directed against IgG) present in 80%
- Antinuclear antibodies present in 25% of cases
- Elevated erythrocyte sedimentation rate
- Elevated levels of gamma globulins (typically IgM and IgG)
- Platelet count may elevate due to inflammation
- Moderate hypochromic normocytic anemia
- Leukopenia (frequent with splenomegaly)
Arthrocentesis may reveal:
- Straw-colored joint fluid that is slightly cloudy and contains flecks
- White blood cell counts at 5,000 to 25,000 per mm (>85%
- IgG may approach serum levels
- Depressed glucose level (may be less than 25
- Pannus formation (i.e., thickening of synovium)
- Cartilage breakdown
- Bone erosion
In later stages of the disease, X rays can reveal joint space narrowing and
- Patient's report of symptoms
- Physician assessment of physical symptoms
- Results of laboratory tests
- American College of Rheumatology criteria (five of the following
seven, with numbers 1 through 4 continuous for at least six weeks): (1) Morning
stiffness greater than one hour; (2) Arthritis in at least three joint groups
with soft tissue swelling or fluid; (3) Swelling involving at least one of the
following joint groups: ploximal interpalangeal, metacarpophalangeal, or wrists;
(4) Symmetrical joint swelling; (5) Subcutaneous nodules; (6) Positive rhematoid
factor test; (7) Radiographic changes consistent with
Treatment is typically aimed at relieving symptoms, preventing joint
degradation, and preserving joint function. Traditional treatment involves a
conservative approach using nonpharmacologic therapy and nonsteroidal
anti-inflammatory drugs for up to a year before resorting to aggressive
therapies. However, as substantial joint destruction can occur within two years
of developing RA, the current recommendation is to treat RA earlier and more
aggressively. Other general treatment strategies include the
- Whole-body rest to reduce systemic inflammatory response and combat
- Articular rest such as joint relaxation techniques, assistive
devices, and splints
- Heat and cold treatment
- Exercise to preserve joint motion, strength, endurance
- Surgery (e.g., carpal tunnel release, resection of metatarsal heads,
total hip or total knee arthroplasty) to address joint destruction, deformation,
or refractory pain
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen,
ketoprofen, naproxen, tolmetin, diclofenac, and diflunisal reduce pain and
inflammation. Gastrointestinal side effects are common and may include ulcers
and bleeding. The recently FDA-approved celecoxib selectively inhibits
cyclooxgenase-2 and has a reduced risk of gastrointestinal side effects. Many
more "COX-2" drugs are expected to be approved shortly.
Disease-modifying antirheumatoid drugs (DMARDs) include gold salts
(injectable or oral), antimalarials (e.g., hydroxychloroquine), penicillamine,
and sulfasalazine. DMARDs also include immunosuppressive drugs such as
methotrexate, azathioprine, and cyclophosphamide. Beneficial effects may not be
apparent for weeks or months. Most DMARDs have serious side effects including
gastrointestinal symptoms, thrombocytopenia, myelosuppression, proteinuria, and
Costicosteroids (glucocorticoids) have both anti-inflammatory and
immunosuppressive effects. Drugs such as prednisone (5 to 15 mg predinsone or
equivalent daily, for short-term use) and methylprednisolone relieve symptoms
quickly and may be given orally or by injection. Side effects include
osteoporosis, mood changes, fluid retention and weight gain, and
Some patients do not respond to individual DMARDs and better results may be
achieved through drug combination. For example, a combination of methotrexate,
hydroxychloroquine, and sulfasalazine may be more effective than methotrexate
Experimental therapy options include the following.
- Zileuton, a 5-lipoxygenase inhibitor, is under FDA review for
treatment of mild synovitis
- Oral Type II collagen
- Recombinant human interleukin-1 receptor antagonist
- Antibodies to TNF-alpha
- Anti-CD4 monoclonal antibodies
- Mycophenolate mofetil
|Complementary and Alternative
The goal of therapy is to decrease inflammation and preserve joint function.
Because some, but not all, cases of RA respond to dietary changes, a trial
should be informative and may be helpful. Proper nutrition is often a mainstay
of complementary therapies. Herbs may be helpful for decreasing the severity and
frequency of attacks. Treatment is long term.
- The most common allergic foods are wheat, corn, and dairy.
Elimination/challenge diets may identify whether these foods constitute a
problem. Avoid foods completely for two weeks, then reintroduce the foods one at
a time, every three days, and note symptoms. Citrus, chocolate, alcohol, red
meat, flour products, spices, and carbonated drinks may also aggravate
- A vegetarian diet high in antioxidants may provide relief from the
symptoms. This diet has high amounts of flavonoids (green tea [Camellia
sinensis], blueberry , elderberry [Sambucus nigra]) and low amounts
of saturated fats.
- A small percentage of people respond dramatically to a diet free of
nightshades. They include peppers, eggplant, tomatoes, and white potatoes. A
month-long trial is recommended.
- Selenium levels are low in people who have RA. One clinical study
demonstrated that selenium combined with vitamin E reduces RA symptoms. Dose is
50 to 75 mcg/day of selenium and 400 to 800 IU of vitamin E.
- Zinc (45 mg/day) and manganese (45 mg/day) have both been found to be
low in persons with RA.
- Omega-3 fatty acids suppress the production of inflammatory compounds
produced by white blood cells. Dose is 1,000 to 1,500 IU/day.
- Bromelain is a proteolytic enzyme that when taken away from food is
an anti-inflammatory (when taken with meals, it acts as a digestive enzyme).
Dose is 2,000 to 2,500 mg bid.
- Quercetin stabilizes mast cells, found in increased numbers in the
synovial membranes of affected joints. Dose is 250 to 500 mg tid away from
Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as teas, dried extracts (capsules, powders),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
- Devil's claw (Harpagophytum procumbens): analgesic,
- Ginseng (Panax ginseng): adaptogen (tonic for long-term
stress), specific for chronic disease or condition and the effects of
- Ginger (Zingiber officinale): antispasmodic, digestive
- Valerian (Valeriana officinalis): sedative, anodyne,
antispasmodic, bitter. Helpful for pain control, especially if pain causes sleep
- Blue flag (Iris versicolor): cholagogue (stimulates liver to
process effects of inflammation)
- Wild yam (Dioscorea villosa): antispasmodic, bitter, specific
for RA, adaptogen
- Horsetail (Equisetum arvense): diuretic, stabilizes connective
- Devil's claw and three to five of the above herbs can be mixed as
either tincture 30 to 60 drops tid, or 1 cup tea tid.
Other herbs to consider to reduce excessive immune response include gana
derma, maitake mushroom (Grifola frondosa), and turmeric (Curcuma
longa). Other anti-inflammatory herbs to consider include boswelia,
sarsaparilla (Smilax species), gotu kola (Centella asiatica), and
ashwaganda (winter cherry, Winthania somnifera).
An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Rhus toxicodendron for arthritis that feels worse in the
morning, in damp, cold weather and/or before a storm, and feels better with
heat, dry weather, and upon moving the joints
- Bryonia alba for arthritis that feels better with pressure,
feels worse with any movement, and/or cold weather, but also feels worse with
- Ruta graveolens for arthritic pains that feel worse after
exertion, feel better after resting, especially with a history of
strains/sprains to the joints
- Calcarea carbonica for arthritis that is associated with
weakness and cold clammy extremities that feel worse in the
May be helpful at decreasing pain, improving joint function, and delaying
May be helpful in relieving symptoms and increasing mobility.
- Side effects of pharmacologic treatment
- Osteoporosis prevention
- Periodic blood tests and X
- Joint infection
- Cardiopulmonary complications
- Systemic vasculitis
- Gastrointestinal complications
- Joint erosion or destruction
- Skin vasculitis
RA varies widely among individuals. Approximately 15% to 20% of cases have an
intermittent course with periods of partial to complete remission. Flare-ups may
involve more joints than were initially affected, but remission periods often
last longer than flare-ups. A further 10% of cases have periods of long clinical
remission. The majority of cases (65% to 70%) are progressive; the rate of
progression can be slow or rapid.
Early age of onset, high rheumatoid factor titer, and elevated erythrocyte
sedimentation rate correspond to a poor prognosis. Involvement of more than 20
to 30 joints and presence of extra-articular symptoms also correspond with a
poor outcome. Women generally have a poorer outcome than men. Individuals
experiencing unrelieved symptoms for two or more years are at increased risk of
premature death due to infection, heart disease, respiratory failure, renal
failure, and gastrointestinal disease.
- Seventy-five percent of female RA patients experience symptom
remission with pregnancy.
- Most DMARDs must be paired with effective
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